Debilitating heel pain
A collection of the conditions treated by The Foot Alignment Clinic
Achilles tendonitis is inflammation and degeneration of the Achilles tendon, and should not be left untreated as there is risk of rupture.Individuals who suffer from Achilles tendonitis often complain that their first steps out of bed in the morning are extremely painful. Another common complaint is pain after steps are taken after long periods of sitting. This pain often lessens with activity.The most common cause is over-pronation. Over-pronation occurs in the gait cycle, when the arch collapses upon weight bearing, adding stress on the Achilles tendon. Custom orthotics to prevent pronation, myotherapy and an exercise program is required to rehabilitate this injury.
Aching legs is described as cramping or aching that occurs in your legs and feet when you are sleeping or immobile for extended periods of time. This is a complicated condition (and may be due to vascular disturbance and or mineral deficiency) but is usually due to increased tension of the myofascial system. Myofascial pain is due to abnormal trigger point activity in the body’s musculoskeletal system, which compromises normal vascular flow (see biomechanics page). Treatment involves custom orthotics to place the feet and legs in the most efficient posture, myofascial massage, acupuncture, dietary therapy and stretching exercises.
Ankle injuries/pain. The most common cause for long term pain after an ankle sprain is poor rehabilitation of a previous ankle sprain. Failure to regain normal proprioception, strength and stamina may result in a faulty foot posture, abnormal biomechanics, altered gait and hence irritation of the body’s tissues. Custom orthotics designed to support the foot in its optimal position reduces the stress on the ligaments, tendons, bones and muscles. An appropriate exercise program is of equal importance.
Alignment problems Changes in posture or poor body mechanics may bring about spinal and lower limb alignment problems and muscle shortening, therefore causing other muscles to be misused and become painful. Faulty alignment is often treated from the spine or core in an outward direction. This is a valid approach but the foundations (i.e. the feet) of a structure must be carefully examined and modified to achieve correct alignment and posture. Custom orthotics prevent excessive internal and/or external rotation of the lower limb and hence correct chronic postural faults.
Bursitis is the inflammation of one or more bursae, or small sacks of oil, in the body. The term bursa (plural bursae) is Latin for purse, which is what a bursa resembles. The bursae rest at the points where internal functionaries, like muscles and tendons, slide across bone. In the bursae’s proper state, they create a smooth and almost frictionless surface over which to glide.When bursitis takes hold, however, those movements that rely on the inflamed bursa become rough and painful.In the lower limb, stressful weight bearing activities may need to be reduced on a temporary basis to allow the inflammation to lessen. Custom orthotics is required to reduce the stress at the ankle or within the foot and to improve the biomechanical efficiency of the structures above and below the bursae. Spinal mobilization , soft tissue stretching and massage as well as anti- inflammatory mediators (laser, pulsed ultrasound, interferential land ice) can be used in a multidisciplinary approach.
Back pain is a very broad term for a multitude of problems. Diagnoses such as slipped disc, facet joint sprain, weak core, sacroiliac up/down slip, in flare or out flare are very common. As a physiotherapist I have seen many chronic conditions described as these improve significantly with good orthotics. Commonly uneven or excessive forces are placed upon the hips which arise from faulty foot posture or real leg length differences. If your back pain gets worse with standing or gets relief by stretching tight hip muscles ( iliopsoas, piriformis, glute medius) then long term alignment from orthotics will help. A rehabilitation guideline would also be prescribed to restore normal muscle balance.
Bunions referred to in the medical community as Hallux Valgus, are one of the most common forefoot problems. Symptoms of bunions include inflammation, swelling, and soreness on the side surface of the big toe. Bunions worsen over time and cause discomfort, difficulty walking, and skin problems such as corns and calluses. Without treatment, the deformity eventually becomes disabling. Custom orthotics to prevent over pronation will help significantly to restore normal gait and less pressure on the Hallux.
Calf tightness a common problem in athletes is tight calf muscles, especially in runners. The symptoms are a gradual tightening in the calf muscles which can get worse when running or improve while running only to tighten up later. Why do they tighten up? You might have a compartment syndrome or a bio mechanical problem in your running style and need orthotics. Over pronation commonly loads the lateral aspect of the calf and hence micro trauma to the tissue. (See biomechanics page).
Compartment syndrome is a condition in which increased pressure within a muscle compartment causes a decrease in blood supply to the affected muscles. The so-called compartments are groups of muscles surrounded by inelastic fascia and thus any swelling of muscles leaves no room for expansion and blood supply is progressively cut-off. What the athlete experiences is pain that begins during activity, progressively worsens, and then ceases during rest. This is distinct from the pain of other overuse injuries. The pain associated with tendonitis usually begins as soon as exercise is started, lessens with continued exercise — as the muscles and tendons warm-up — and then returns after exercise is stopped. Conservative treatment consists of myofascial massage, acupuncture, stretching exercises and custom orthotics to correct any biomechanical anomalies. If this fails surgery is very effective.
Disc Bulge. Intervertebral discs are spongy cushions found between the vertebrae of the spine. These discs have a number of important functions including shock absorption, keeping the vertebral column stable, and offering the vertebrae ‘pivot points’ to allow movement. The symptoms of a damaged disc can vary according to its location and severity, but general signs include: localised pain, pain radiating down the legs, worsening pain associated with bending over or sitting down for a long time, worsening pain associated with activities like coughing or sneezing. Current trends in management emphasize correcting faulty postures, balancing the muscle tensions around the pelvis and reactivating the core muscles. Custom orthotics can have a very significant role in chronic conditions.
Flat feet/ Over-pronation, or flat feet, is a common biomechanical problem that occurs in up to 80% of the population. This motion can cause extreme stress or inflammation on entire lower limb, pelvis and spine. There are many causes of flat feet. Obesity, pregnancy or repetitive pounding on a hard surface can weaken the arch leading to over-pronation. Often people with flat feet do not experience discomfort immediately, and some never suffer from any discomfort at all. However, when symptoms develop and become painful, standing, walking or running becomes awkward and painful. Over-Pronation is effectively treated conservatively (non-surgical treatments) with custom orthotics.
Hamstring tightness is a very common and complex condition. Causes are either due to neural or myofascial tightness. Environmental factors such as a desk job may be the cause, or intrinsic postural faults can compound both neural tightness and myofascial loading. Piriformis syndrome, ITB friction syndrome and poor rotational control of the lower limb all need to be considered when addressing this issue. Custom orthotics can control pronation and reduce anterior pelvic tilt thus releasing the pressure on the hamstrings.
Headaches can be caused from common postural conditions and faults. Anterior pelvic tilt creates increased thoracic kyphosis and “the forward head posture”. This creates pain producing trigger points in the occipital region which may be the cause of common tension headaches. If your headaches are relieved by treatment to your neck or back but continually return, then a full posture assessment may be required, including foot and gait analysis.
Heel spurs. A heel spur develops as an abnormal growth of the heel bone. Calcium deposits form when the plantar fascia pulls away from the heel area, causing a bony protrusion, or heel spur to develop. The plantar fascia is a broad band of fibrous tissue located along the bottom surface of the foot that runs from the heel to the forefoot. Heel spurs can cause extreme pain in the rear foot, especially while standing or walking. This stretching of the plantar fascia is usually the result of over-pronation (flat feet), but people with unusually high arches (pes cavus) can also develop heel spurs. The cause is usually over-pronation (flat feet), a custom orthotic with rearfoot posting and longitudinal arch support is an effective device to reduce the over-pronation, and allow the condition to heal. Other common treatments include stretching exercises, losing weight and wearing shoes that have good cushioning.
Hip pain. Excessive rotational forces coming from the ground up are transmitted throughout the entire body. The hip is a ball and socket joint designed to absorb strain in many planes of movement. If there is excessive motion in one plane (such as internal rotation) wear and tear (arthritis) may arise. Ligaments, cartilage and tendons can all degenerate with faulty biomechanics. Custom orthotics are designed to realign the body in its most efficient weight bearing posture minimizing and neutralizing the strain put on the lower limb. Orthotics are always coupled with manual therapy and an exercise program to correct imbalance in this area.
Illotibial band friction syndrome is an overuse injury that produces pain on the lateral knee during running and, occasionally, cycling. Pain is generally caused by an unusually tight ITB, the undersurface of which frictions over the lateral femoral condyle. This occurs during knee flexion and extension at approximately 30 degrees knee flexion when running and cycling, when the ITB flicks over the lateral femoral condyle. This process leads to friction, micro trauma, inflammation – and hence pain develops. The two most common predisposing factors that lead to ITBFS in athletes are anterior hip inflexibility and poor rotational control of the lower limb. Lower-limb stability, strength and balance exercises are crucial in rectifying ITBFS predisposing factors. Custom orthotics are an excellent way to aid the rotational control of the lower limb.
Knee pain Excessive rotational forces coming from the ground up are transmitted throughout the entire body. The first port of call is the knee, and there are many structures which are prone to excessive wear and tear if the foot posture is not ideal(see biomechanics page). Ligaments, meniscus, cartilage and tendons can all degenerate with faulty biomechanics. Custom orthotics are designed to realign the body in its most efficient weight bearing posture.
Leg length difference. A majority of people have a measurable leg length difference of 5mm or more, although most people adapt to the difference with no apparent ill effects. Unfortunately, some do not, and the effects range from low back or sacroiliac pain to hip, knee, or foot problems. A number of causes can contribute to leg length discrepancy, including: Any bone in the leg ever broken, particularly during growth years, Congenital differences or uneven growth, Disease-caused shortening of the muscles and connective tissue, a common after-effect of polo. Surgically-induced differences, especially common after hip replacement surgery, Compensation for problems elsewhere in the body, such as pelvic or spinal scoliosis. Short leg syndrome or anatomical (structural) or functional (adaptive) leg length discrepancy, is often treated using custom orthotics. A CT scanogram is routine for diagnosing leg length difference.
Muscle imbalance refers to the balance between strength and length of muscles acting around one or more joints. Muscles respond to the stresses placed upon them. Therefore it is of utmost importance to balance the stresses received by the body from the ground up.(see biomechanics page). Overloading muscular compartments leads to micro trauma, myofascial restriction, tightness, weakness and pain. Treatment for this condition begins with expert diagnosis using muscle testing and observation of movement and posture. Modalities such as massage, stretching and strengthening are coupled with orthotic therapy to resolve imbalance.
Morton’s neuromais localized pain in the interspace between the third and fourth toes due to nerve compression. Flat feet can cause the nerve to be pulled toward the middle (medially) more than normal, which can cause irritation and possibly enlargement of the nerve. It can be relieved by a custom-fitted orthotic that helps maintain the natural posture of the foot. Conservative treatment does not work for all patients and minor surgery may be necessary.
Metatarsalgia occurs when one or more of the metatarsal heads become painful and/or inflamed, usually due to excessive pressure over a long period of time. It is common to experience acute, recurrent, or chronic pain with this common foot condition. This can inhibit the walking process and lead to extreme discomfort in the forefoot. Factors that can cause excessive pressure in the ball of foot include shoes with heels that are too high orparticipating in high impact activities without proper footwear and/or orthotics. Also as we get older, the fat pad in our foot tends to thin out, making us much more susceptible to pain in the ball of the foot. Orthotics designed to relieve ball of foot pain usually feature a metatarsal pad. The orthotic is constructed with the pad placed behind the ball of the foot to relieve pressure, and redistribute weight from the painful area to more tolerant areas.
Osgood Schlatter disease During your child’s adolescent growth spurt, his or her bones grow rapidly. If your child is involved in a lot of running and jumping activities during this time, he or she is at risk of developing Osgood-Schlatter disease (tibial tuberosity apophysitis), an overuse syndrome that causes pain, swelling and tenderness just below the kneecap where the patella tendon inserts onto the tibia. Short term rest, anti inflammatory modalities and orthotics to minimize biomechanical stress are prescribed.
Osteoarthritis is a joint disease that mostly affects the cartilage. Cartilage is the slippery tissue that covers the ends of bones in a joint. Healthy cartilage allows bones to glide over one another. It also absorbs energy from the shock of physical movement. In osteoarthritis, the surface layer of cartilage breaks down and wears away. This allows bones under the cartilage to rub together, causing pain, swelling, and loss of motion of the joint. Over time, the joint may lose its normal shape. This may be due to single event trauma (such as a football injury), ormay be due to a lifetime of inefficient biomechanics. Promoting correct alignment will minimize the ageing of joints. Orthotics, Pilates, yoga and regular manual therapy to promote efficient posture is highly recommended.
Pelvic imbalance may arise from a multitude of causes including lifestyle and occupational habits. Interestingly the shape of your feet and your leg length can put uneven strain on your pelvis. A recurrent pelvic imbalance (“upslip”, “inflare” etc.) may be due to an old ankle injury, leg length difference or possibly excessive pronation on one or both of your feet. A full biomechanical assessment is required to differentiate these causes. Manual therapy, exercise programs and orthotics are required to resolve this issue.
Patella maltracking. If your base of support (your feet) is not stable then the muscles of the lower limb, pelvis and back are overworking to compensate. A pronated foot is likely to overwork the lateral compartments of the calf and thigh hence resulting in micro trauma, soft tissue fibrosis and overall loss in elasticity. Myofascial tightness in the ITB, Tensor fascia late and vastus lateralis tend to pull the knee cap out of its groove. This mistracking causes pain, cartilage wear and a felling of giving way. Treatment requires a series of soft tissue releases to reverse the myofascial restriction, orthotics to stabilize the pronated foot and strength program to reestablish medial control of the kneecap.
Piriformis syndrome is a myofascial syndrome whereby the piriformis muscle (due to excessive work in trying to stabilize the hip) develops trigger points. Increased tension in this muscle can cause entrapment of the sciatic nerve and hence sciatic like symptoms. As the piriformis is an external rotator of the hip it is under constant tension when the foot internally rotates (pronation) and hence a custom orthotic that is designed to prevent over pronation is a very effective treatment for this syndrome. Massage, stretching and stabilization exercises are also advisable.
Plantar fasciitis The plantar fascia is a thick fibrous band of tissue in the bottom of the foot which runs from the heel to the base of the toes. When placed under too much stress, the plantar fascia stretches too far and frays, or tears, resulting in inflammation of the fascia and the surrounding tissues .Pain is usually worse first thing in the morning. After a few minutes it eases as the foot gets warmed up, but can get worse again during the day especially if walking a lot. If the foot over pronates or is too stiff then they may be prone to this injury because as the foot rolls in, the arch ligament is stretched more, putting more strain on it. Custom orthotics is recommended to remove the constant strain on this tissue (see biomechanics page).
Recurrent muscle injuries (calf, quads, groin or hamstrings) If your base of support is not stable then the muscles of the lower limb, pelvis and back are overworking to compensate. A pronated foot is likely to overwork the lateral compartments of the calf and thigh (quads, ITB, hamstrings and hip rotators.) A full biomechanical assessment is required to resolve these issues.
Severs Disease The condition occurs most commonly in children between the ages of 8 and 14 years. Severs Disease is characterised by activity-related pain that occurs on the back of the heel, where the Achilles attaches on the heel bone which is alleviated when the child walks on their toes. The child may have swelling in the area, and tenderness to the touch. Sports requiring lots of running, jumping, and other high impact activities are particularly associated with Severs. Kids that are prone to Severs are usually very active, are having a growth spurt, have tight calf muscles and are pronators .Thus ice, massage and orthotics to prevent excessive pronation are effective treatments.
Sciatica -pain along the large sciatic nerve that runs from the lower back down the back of each leg. Sciatica is usually caused by pressure on the sciatic nerve from a herniated disc and can also be the result of “double crush syndrome” whereby the piriformis muscle also adds to the neural entrapment.Sciatica occurs most frequently in people between 30 and 50 years of age. Often a particular event or injury does not cause sciatica, but rather it may develop as a result of general wear and tear on the structures of the lower spine. Therefore minimizing imbalance at the hips and pelvis should be a long term goal and is achieved by manual therapy, exercise and custom orthotics to aid biomechanical efficiency
Sesamoiditis is a common ailment that affects the forefoot, typically in young people who engage in physical activity like running or dancing. Its most common symptom is pain in the ball-of-the-foot, especially on the medial or inner side. The term is a general description for any irritation of the sesamoid bones, which are tiny bones within the tendons that run to the big toe. Like the kneecap, the sesamoids function as a pulley, increasing the leverage of the tendons controlling the toe .Minor cases call for a strict period of rest, along with the use of a custom orthotic to reduce pressure on the affected area. This may be accomplished by placing a metatarsal pad away from the joint so that it redistributes the pressure of weight bearing to other parts of the forefoot
Shin splints Pain or tenderness along the inside of the shin, usually about halfway down the shin. Pain on palpation of the shin. Pain is most severe at the start of a run, but may disappear during a run, as the muscles loosen up. This is different to a stress fracture, where there is pain during weight bearing activities (walking, stair-climbing) Shin splints are caused by: Inflexible calf muscles and tight Achilles tendons, overpronation (feet rotate too far inward on impact) excessive running on hard surfaces, Incorrect or worn shoes Overtraining, or a rapid increase in training load or intensity. Custom orthotics will reduce soft tissue loading (see biomechanics page)
Tendonitis (tibialis posterior, patellar tendonitis, Achilles) Tendonitisis an inflammation of the tendon. Tendonitis of the ankle can involve the Achilles tendon, the posterior tibial tendon, or the peroneal tendon. All forms of tendonitis cause pain, swelling, and tenderness in the tendon area involved. The onset may be rapid, such as with an athletic injury. Immediate treatment involves immobilizing the area, elevation, and limiting weight bearing, applying ice, and using nonsteroidal anti-inflammatory drugs (NSAIDs) to decrease inflammation. Athletic participation should be limited when the tendon is still inflamed, as there is a significant risk of rupture.
Weak ankles is generally the result of structural hyper mobility (when the body’s ligaments have a high proportion of elastin fibers), or can be the result of past injuries. In either case the postural support for the sub talar joint is not sufficient and the foot rolls regularly causing pain and swelling. Custom orthotics designed to support the foot in its optimal position reduces the stress on the ligaments, tendons, bones and muscles. An appropriate exercise program is of equal importance.